Detecting coeliac disease in general practice

While coeliac disease affects approximately one in 70 Australians, making it one of the most common autoimmune diseases likely to be encountered in general practice, it has been found that about 80% of people experiencing it remain undiagnosed.
 
Dr Jason Tye-Din, gastroenterologist and Chair of the Medical Advisory Committee of Coeliac Australia, told newsGP that GPs are central to detecting this common disease.
 
‘As the first port of call, GPs are actually the most crucial player in this whole interaction,’ he said. ‘GPs who are mindful of the at-risk features that could prompt testing for the disease can play a really important role in this process by detecting it early.’
 
However, Dr Tye-Din acknowledges that identifying the disease can be difficult. He hopes his article, ‘Interpreting tests for coeliac disease: Tips, pitfalls and updates’ in the latest edition of the Australian Journal of General Practice (AJGP) will provide GPs with relevant information and guidance on the subject.
 
‘It’s a common situation but a challenging one for GPs, and hopefully the paper will help provide some guidance on navigating the different ways to reach an outcome,’ he said.

Part of the reason coeliac disease can be difficult to diagnose is the fact its symptoms can be very broad and also indicative of other conditions, such as irritable bowel syndrome. A further complicating factor is that the disease can also manifest in ‘extra-intestinal’ symptoms.
 
‘Migraine headaches, anaemia, infertility, osteoporosis, liver disease, joint aches and pains, skin disease, neurological manifestations – all of those sorts of things are now in fact considered more common than the typical gastrointestinal symptoms,’ Dr Tye-Din said.
 
‘A common scenario might be a middle-aged woman presenting with some iron deficiency, chronic fatigue, infertility or recurrent pregnancy loss and not necessarily having any gastrointestinal symptoms whatsoever.’
 
This does presents the problem that many patients who could be deemed at-risk will not in fact be experiencing coeliac disease. According to Dr Tye-Din, GPs need to test about 30 at-risk patents before receiving a positive hit. But while this may seem inefficient, it is the best approach currently available.
 
‘There’s no other way to detect it, apart from GPs just having a very high index of suspicion or at least a low threshold for testing,’ Dr Tye-Din said.  
 
‘So think of adding in coeliac serology or coeliac antibody testing as part of a patient’s work-up when people present with lethargy or gut symptoms. It is worth considering it as one of the differential diagnoses.’
 
Although such an approach may raise the possibility of over-screening, Dr Tye-Din believes positive outcomes for patients have demonstrated its worth.
 
‘Some studies have shown that it is cost-effective to screen for coeliac disease in patients presenting with irritable bowel-type symptoms. Because when you get a positive hit and there is a definitive treatment, the outcome for that individual resolves what could otherwise be chronic symptoms that go inadequately treated,’ he said.
 
A current trend of people deciding of their own accord to adopt a gluten-free diet – before they receive any definitive diagnosis to confirm this course of action – is another complicating factor relating to detection and diagnosis of coeliac disease.
 
‘This is a really common issue that GPs face, and to some extent it takes a compassionate approach, accepting that patients are having troubling symptoms,’ Dr Tye-Din said. ‘But it also takes a thorough systematic approach to trying to work out how to get the best outcome for the patient.
 
‘In other words, work through the diagnosis and test properly for coeliac disease. If these people are gluten-free already, standard serology won’t work unless they reintroduce gluten into their diet, so that’s one of the key points.
 
‘Often [these patients] are very reluctant to get tested because they’re anxious about causing their symptoms to return. Many people say, “If I feel better on this diet, why can’t I just follow it? Why do I need to go back on gluten to get tested?”
 
‘So the GP needs to be informed and have a compassionate but guiding approach to ensuring patients understand why they need to be tested and the benefits of making the diagnosis.’
 
Access Dr Tye-Din’s paper in the latest edition of AJGP for further information on coeliac disease testing in general practice.

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